A 25-year dynamic ecological analysis of psychiatric hospital admissions and prison committals: Penrose's hypothesis updated.

AIMS: There is renewed interest in the inverse association between psychiatric hospital and prison places, with reciprocal time trends shown in more than one country. We hypothesised that the numbers of admissions to psychiatric hospitals and committals to prisons in Ireland would also correlate inversely over time (i.e. dynamic measures of admission and committal rather than static, cross-sectional numbers of places). METHOD: Publicly available activity statistics for psychiatric hospitals and prisons in Ireland were collated from 1986 to 2010. RESULTS: There was a reciprocal association between psychiatric admissions and prison committals (Pearson r=-0.788, p<0.001), an increase of 91 prison committals for every 100 psychiatric hospital admissions foregone. CONCLUSION: Penrose's hypothesis applies to admissions to psychiatric hospitals and prisons in Ireland over time (dynamic measures), just as it does to the numbers of places in psychiatric hospitals and prisons in Ireland and elsewhere (static, cross-sectional measures). Although no causal connection can be definitively established yet, mentally disordered prisoners are usually known to community mental health services. Psychiatric services for prisons and the community should be linked to ensure that the needs of those currently accessing care through prisons can also be met in the community.

Forensic psychiatry and Covid-19: accelerating transformation in forensic psychiatry.

Swift medically led scientifically informed responses to the Covid-19 epidemic nationally have been demonstrably superior to other, non-scientific approaches. In forensic psychiatry and across all psychiatric services, urgent and clinically led responses have underlined redundancies and confusions in the governance of mental health services and a vacuum in policy makers. For the future, a greater emphasis on services for patients with schizophrenia and other severe, enduring mental disorders must aim at reducing standardised mortality ratios, managing risk of violence and improving hard outcomes such as symptomatic remission, functional recovery and forensic recovery of autonomy. This will require more use of information technology at service level and at national level where Scandinavian-style population-based data linkage research must now become legally sanctioned and necessary. A national research and development centre for medical excellence in forensic psychiatry is urgently required and is complimentary to and different from quality management.

Anticholinergic burden in schizophrenia and ability to benefit from psychosocial treatment programmes: a 3-year prospective cohort study.

BACKGROUND: Many medications administered to patients with schizophrenia possess anticholinergic properties. When aggregated, pharmacological treatments may result in a considerable anticholinergic burden. The extent to which anticholinergic burden has a deleterious effect on cognition and impairs ability to participate in and benefit from psychosocial treatments is unknown. METHOD: Seventy patients were followed for approximately 3 years. The MATRICS consensus cognitive battery (MCCB) was administered at baseline. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. Ability to benefit from psychosocial programmes was measured using the DUNDRUM-3 Programme Completion Scale (D-3) at baseline and follow-up. Psychiatric symptoms were measured using the PANSS. Total antipsychotic dose was measured using chlorpromazine equivalents. Functioning was measured using the Social and Occupational Functioning Assessment Scale (SOFAS). RESULTS: Mediation analysis found that the influence of anticholinergic burden on ability to participate and benefit from psychosocial programmes was completely mediated by the MCCB. For every 1-unit increase on the ACB scale, change scores for DUNDRUM-3 decreased by -0.27 points. This relationship appears specific to anticholinergic burden and not total antipsychotic dose. Moreover, mediation appears to be specific to cognition and not psychopathology. Baseline functioning also acted as mediator but only when MCCB was not controlled for. CONCLUSIONS: Anticholinergic burden has a significant impact on patients' ability to participate in and benefit from psychosocial treatment programmes. Physicians need to be mindful of the cumulative effect that medications can have on patient cognition, functional capacity and ability to benefit from psychosocial treatments.

Association and spreading of the Drosophila dosage compensation complex from a discrete roX1 chromatin entry site.

In Drosophila, dosage compensation is controlled by the male-specific lethal (MSL) complex consisting of MSL proteins and roX RNAs. The MSL complex is specifically localized on the male X chromosome to increase its expression approximately 2-fold. We recently proposed a model for the targeted assembly of the MSL complex, in which initial binding occurs at approximately 35 dispersed chromatin entry sites, followed by spreading in cis into flanking regions. Here, we analyze one of the chromatin entry sites, the roX1 gene, to determine which sequences are sufficient to recruit the MSL complex. We found association and spreading of the MSL complex from roX1 transgenes in the absence of detectable roX1 RNA synthesis from the transgene. We mapped the recruitment activity to a 217 bp roX1 fragment that shows male-specific DNase hypersensitivity and can be preferentially cross-linked in vivo to the MSL complex. When inserted on autosomes, this small roX1 segment is sufficient to produce an ectopic chromatin entry site that can nucleate binding and spreading of the MSL complex hundreds of kilobases into neighboring regions.

Violence, homicide and suicide: strong correlation and wide variation across districts.

BACKGROUND: The clinical assessment and management of the risk of violence and suicide by people with mental illness may have to focus on environmental as well as individual factors. AIMS: To investigate possible associations between violence, homicide and suicide rates, population density and indices of deprivation, with particular reference to inner-city boroughs. METHOD: Coroners' statistics in London for homicide and suicide were obtained, with police-reported homicide and violence rates as a validity check. Correlations were made between these data and population density, the Jarman under-privileged areas score, and the Mental Illness Needs Index for each of the 32 London boroughs. RESULTS: Homicide rates had a 14.3-fold range, suicide a 4.4-fold range and interpersonal violence a 6.6-fold range. The variables under study were strongly correlated with each other. Rates were highest in boroughs with high population density and deprivation scores. The associations persisted when covarying for deprivation, age structure or population density. CONCLUSIONS: Because violence, homicide and suicide are so closely correlated, they are likely to be valid indices of the differences between adjacent boroughs; this has implications for the delivery of preventive and mental health services and for clinical management of risk.

Fear and anger in delusional (paranoid) disorder: the association with violence.

We report a series of 15 patients with delusional (paranoid) disorder as defined in DSM-III-R. All were supervised by a forensic psychiatry service after violent or threatening acts. We hypothesised that delusions and actions in these patients would be congruent with an abnormal mood characterised by fear and anger. Informants and the patients indicated a pervasive and persistent abnormality of mood (fear and defensive anger), with delusions and actions that were congruent with this mood during the offence and for over a month before. Other behaviours, such as fleeing or barricading to avoid delusional persecutors, were also consistent with congruence of mood and delusions. In all cases, violent acts and mood were congruent, but in three cases the violent act was unrelated to delusions. Although a study such as this does not demonstrate that the mood abnormality is primary, we believe moods of fear and anger in delusional disorder are not sufficiently recognised as part of the disorder.

Parental hostage takers.

Three men presented to a single regional secure psychiatric unit over a twelve-month period, after taking their youngest child hostage in their own homes because of a threatened separation from the family. In each case the episode had escalated because of hostility to police involvement in what for them was a typical domestic upheaval. All cases ended without injury. In each man, substance abuse, a family history of domestic violence and fears of rejection were prominent, and the recent birth of a child may have been an added precipitant. There may be a common family structure which predisposes to such situations. Psychiatric intervention was deemed appropriate, with some evidence of benefit for the two men who engaged in treatment.

Patterns of denial in sex offenders.

Men convicted of sex offences (N = 102) were interviewed in two prisons. Cluster analysis was used to generate three groups according to pattern of denial; a fourth group was composed of men who denied their offence altogether. The groups differed in their ethnic make-up, offence type and past history of sexual offending.

Hot-headed or impulsive?

A sample of men in prison was interviewed and rated for the presence of six behaviours commonly thought to be impulsive: alcohol abuse (CAGE positive), sedative dependence, other drug abuse, pathological gambling, repeated aggression and self-harm. They were also asked to complete the EPQ and 15 questionnaires. Out of 61 men on a 'special protection, wing, 51 agreed to take part. We found that the score on the Impulsiveness scale of the 15 correlated with the number of disorders present in individuals, even when corrected for age. Pathological gambling and self-harm did not correlate with the presence of any of the other behaviours.

Pulmonary function after bone marrow transplantation for chronic myeloid leukaemia.

Pulmonary function was measured before and at intervals after treatment in 44 patients who received a bone marrow transplant for chronic myeloid leukaemia in the chronic phase. All patients were treated with cytotoxic drugs, total body irradiation, and post-graft immunosuppression. Thirty four patients surviving for 12 months were followed at three monthly intervals and 16 patients for 24 months. Fifteen patients received unmanipulated donor marrow cells and 29 patients received donor marrow cells depleted of lymphocytes ex vivo with the monoclonal antibody Campath-1. The 21 patients treated early in this study received 10 Gy of total body irradiation whereas the 23 patients treated more recently, who were all T lymphocyte depleted, received 12 Gy. Pretransplant lung function for the group was normal and was similar in survivors (n = 34) and nonsurvivors (n = 10), and in smokers (n = 8) and non-smokers (n = 36). (Carbon monoxide transfer factor--TLCO) was under 75% of predicted normal in nine patients before transplantation. TLCO, carbon monoxide transfer coefficient (KCO), FEV1, and vital capacity (VC) values were lower 6 and 12 months after bone marrow transplant than initially. The greatest decline was in TLCO, from an initial value of 89% to 66% at 6 and 70% at 12 months. The 16 longer term survivors showed significant recovery of function between 6 and 24 months after bone marrow transplant for TLCO, KCO, and VC, the increase ranging from 6.3% to 7.3% predicted. Airflow obstruction (FEV1/VC ratio less than 70%) developed in one patient. The major factors associated with deterioration in pulmonary function at 6 and 12 months after transplantation in the 34 survivors (stepwise multiple regression analysis) were (a) transplantation with T cell depleted donor marrow (p less than 0.005) and higher total body irradiation dose (p less than 0.02) with a fall in KCO and an increase in the FEV1/VC ratio; (b) chronic graft versus host disease with a fall in VC (p less than 0.01); and less fall in KCO (p less than 0.01); and (c) acute graft versus host disease with a fall in FEV1 (p less than 0.01). It is considered that most patients who survive the short term risks of bone marrow transplant have only minor long term impairment of pulmonary function.